M10.05.03 History Taking in the Head and Neck

History taking is a crucial component of the clinical assessment of the head and neck. Accurate and thorough history gathering enables the clinician to identify potential issues, guide physical examination, and formulate differential diagnoses. This section outlines the essential aspects of history taking in the head and neck region, including key questions, patient interaction tips, and common abnormal conditions.

Key Components of History Taking

1. Chief Complaint
   • The primary reason for the patient’s visit.
   • Examples: “I have a headache,” “I have difficulty swallowing.”
2. History of Present Illness (HPI)
   • Detailed description of the current problem.
   • Includes onset, location, duration, characteristics, aggravating and relieving factors, associated symptoms, and treatments tried.

HPI Structure: OLDCARTS

• Onset: When did the symptoms start?
• Location: Where is the symptom located?
• Duration: How long have the symptoms lasted?
• Characteristics: What is the nature of the symptoms (e.g., sharp, dull, throbbing)?
• Aggravating Factors: What makes the symptoms worse?
• Relieving Factors: What makes the symptoms better?
• Timing: Is there a pattern or specific time when the symptoms occur?
• Severity: How severe are the symptoms on a scale of 1 to 10?

Past Medical History

• Previous Head and Neck Issues
  • History of head trauma, surgeries, infections, or chronic conditions.
• Chronic Diseases
  • The presence of systemic conditions like hypertension or diabetes can affect the head and neck.

Family History

• Genetic Predispositions
  • Family history of head and neck cancers, thyroid disease, or genetic disorders affecting the region.

Social History

• Lifestyle Factors
  • Smoking, alcohol use, occupational exposures, and recreational drug use.
• Living Conditions
  • Environmental factors that could influence health.

Review of Systems (ROS)

• General: Weight loss, fever, fatigue.
• Skin: Changes in skin color, rashes.
• Eyes: Vision changes, pain, discharge.
• Ears: Hearing loss, tinnitus, discharge.
• Nose: Congestion, bleeding, anosmia.
• Mouth/Throat: Soreness, hoarseness, dysphagia.
• Neck: Swelling, lumps, stiffness.

Common Abnormal Conditions in the Head and Neck

• Headache Disorders
  • Migraine, tension-type headache, cluster headache.
• Thyroid Disorders
  • Hypothyroidism, hyperthyroidism, thyroid nodules, thyroid cancer.
• Infectious Conditions
  • Sinusitis, otitis media, pharyngitis, tonsillitis.
• Structural Abnormalities
  • Deviated septum, nasal polyps, goiter.
• Cancers
  • Oral cancer, laryngeal cancer, lymphomas.
• Neurological Disorders
  • Bell’s palsy, trigeminal neuralgia, temporomandibular joint disorders.

Table 1: Key Questions for Head and Neck History

Key Points to Remember

• A comprehensive history is essential for accurate diagnosis and effective management of head and neck conditions.
• Use a systematic approach like OLDCARTS for HPI to ensure all aspects of the symptoms are covered.
• Consider the patient’s past medical, family and social history to identify risk factors and potential underlying conditions.
• Include a thorough review of systems to detect associated symptoms that might be relevant.

Bibliography

1. Bates, B., & Dains, J. E. (2018). Bates’ Guide to Physical Examination and History Taking. Wolters Kluwer.
2. Macleod, J., & Mathew, R. (2015). Clinical Examination: A Systematic Guide to Physical Diagnosis. Elsevier Health Sciences.
3. Swartz, M. H. (2019). Textbook of Physical Diagnosis: History and Examination. Elsevier.
4. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2018). Seidel’s Guide to Physical Examination. Elsevier.